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La evidencia sugiere que los síntomas pulmonares a largo plazo y el deterioro funcional ocurren en una proporción de individuos después de la infección por SARS-CoV-2. Aunque aún no se ha determinado la proporción de pacientes afectados, los médicos se enfrentan cada vez más a pacientes que informan síntomas respiratorios y deterioro más allá de la fase aguda de COVID-19. Ante la necesidad de protocolizar las conductas de tratamiento, la Asociación Colombiana de Neumología y Cirugía de Tórax (Asoneumocito) conformó un grupo de trabajo para desarrollar recomendaciones informadas y basadas en la evidencia, por consenso de expertos, para el manejo de las complicaciones respiratorias en el paciente pos-COVID-19. Recomendaciones realizadas por profesionales de distintas áreas de Asoneumocito con el propósito de ayudar al profesional clínico en atención primaria en el manejo de las posibles complicaciones respiratorias que pueden aparecer durante los meses posteriores al cuadro agudo de la enfermedad causada por el coronavirus (COVID-19) y estandarizar su seguimiento. Métodos. La construcción del documento se desarrolló en 6 etapas: 1. Definición de las preguntas objeto de investigación y contenido, 2. Búsqueda, tamización, evaluación y selección de la evidencia, 3. Elaboración de resumen de evidencia dando respuesta a las preguntas objeto, 4. Discusión en paneles formales, 5. Generación de recomendaciones y 6. Redacción y construcción del documento de consenso. Resultados. Los 85 participantes llegaron a un consenso y formularon 71 recomendaciones en relación con los siguientes enfoques: 1. Definición síndrome Post-covid, 2. Rehabilitación pulmonar y neuromuscular, 3. Función pulmonar, 4. Radiología e imágenes diagnósticas en síndrome pos-COVID-19, 5. Manejo anticoagulante y tromboembolismo pos-COVID-19, 6. Secuelas en vía aérea – broncoscopia, 7. Fibrosis pulmonar y neumonía de organización secundaria y 8. Consideraciones oxigenoterapia. Conclusión. Las recomendaciones formuladas deben servir como una guía provisional para facilitar el tratamiento de los pacientes con síndrome pos-COVID-19 pulmonar. A medida que surja nueva evidencia, es posible que sea necesario reconsiderar y revisar cuidadosamente estas recomendaciones.

El presente documento resume el marco de colaboración denominado “Red Colombiana de Hipertensión Pulmonar” entre miembros de diversas instituciones y especialidades médicas y paramédicas que tienen intereses académicos y científicos en el diagnóstico, tratamiento y/o investigación en áreas diversas de la Hipertensión Pulmonar. Esta iniciativa denominada con el acrónimo “HAPredco”, se justifica ampliamente por la relevancia científica de viabilizar un intercambio gremial, transdisciplinar y continuo mediante una Plataforma de Acción Continuada (PAC) de gestión de la información, experiencias, bases de datos y experticias alrededor de la hipertensión pulmonar.

Alba Ramírez-Sarmiento,1– 3 Orlando Aya,3,4 Diana Cáceres-Rivera,1,2 Carlos F Reyes,2– 4 Angela Espitia,1,2 Camilo Pizarro,3,4 Joaquim Gea,5,6 Victor R Castillo,7,8 Mauricio Orozco-Levi1– 3,6 1Respiratory Department, Instituto Cardiovascular y Hospital Internacional de Colombia, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 2EMICON Research Group MINCIENCIAS, Bogotá, Cundinamarca, Colombia; 3Universidad de Santander (UDES), Bucaramanga, Santander, Colombia; 4Department of Critical Care, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 5Respiratory Department, Parc de Salut Mar, Barcelona, Catalonia, Spain; 6CEXS-Universidad Pompeu Fabra, Barcelona, Catalonia, Spain; 7Department of Cardiovascular Surgery, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia; 8Biomedical and Translational Research Group, Fundación Cardiovascular de Colombia, Floridablanca, Santander, ColombiaCorrespondence: Mauricio Orozco-LeviRespiratory Department, ICV-HIC, Fundación Cardiovascular de Colombia, Calle 155a no. 23-58, El Bosque, Floridablanca, Santander, ColombiaTel +57 3175741421Email mauricioorozco@fcv.orgBackground: Bronchoaspiration of content that accumulates in the supraglottic area (eg, saliva, gastroesophageal reflux) is a risk factor for ventilator-associated pneumonia. A continuous supraglottic suction system may decrease the risk of bronchoaspiration in these patients.Objective: (1) Constructing a conceptual model and functional prototype of a continuous supraglottic suction device for use in humans; (2) defining functional characteristics in ex vivo swine head models; and (3) evaluating its efficacy and safety in mechanically ventilated patients.Methods: Study conducted in three phases. First phase: definition of distances and diameters of the triangle determined by dental arch, posterior oropharynx and vallecula, and diameter of the oropharynx in axial projection; and identification of the declining area of supraglottic suction. Second phase: design engineering and functional prototype evaluated in ex vivo models. Third phase: evaluation of device use in terms of safety and efficacy in ventilated patients.Results: We obtained a final functional model of the SUPRAtube device injected into PVC for medical use. Device effectiveness in in vitro simulation showed a high and fast suction capacity of liquid and thick volumes. Study of swine heads allowed to validate the shape, size and functional fenestration of the device. Study in intubated and mechanically ventilated patients showed a high supraglottic suction capacity and the absence of local adverse events during 72 (7– 240) hours of continuous operation.Conclusion: Our study describes the process of conceptualization, design and production of a practical, safe, low-cost continuous supraglottic suction device without representing antibiotic pressure, which appears to be a new complementary preventive strategy for the standard management of intubated and mechanically ventilated patients.Keywords: mechanical ventilation, bronchoaspiration, supraglottic suction, SUPRAtube, endotracheal tube, gastroesophageal reflux

Introducción: Los procedimientos de traqueostomía van en aumento en las unidades de cuidados intensivos en el adulto, por lo que las complicaciones asociadas a este procedimiento también incrementan. Se ha identificado que la traqueostomía puede conllevar a complicaciones tanto preoperatorias como postoperatorias, que varían ampliamente entre un 5-40%, entre las más frecuentes están, estenosis traqueal, fístula traqueoesofágica, hemorragia, lesión peristomal, decanulación, infecciones, entre otras, que podrían causar la muerte hasta en 1,4% de las personas. Sin embargo, a nivel mundial muy pocos estudios abordan los conceptos causales o factores de riesgo mecánicos y no mecánicos de este importante tema. Objetivo: Revisar el alcance de la literatura científica disponible sobre las complicaciones de origen mecánico y no mecánico asociadas a la traqueostomía en pacientes adultos en las unidades de cuidados intensivos entre el periodo 2015-2020. Materiales y métodos: se establecieron la pregunta de investigación con metodología “Patient, Intervention, Comparation, Outcome, Time (PICOT)” y los criterios de inclusión para la búsqueda de los referentes bibliográficos de estudios observacionales y experimentales. La información fue consultada en las bases de datos PubMed y EBSCO y los artículos científicos seleccionados fueron los publicados entre los años 2015-2020. Como guía metodológica y de calidad para el presente estudio se utilizó la lista de chequeo PRISMA-ScR. Resultados: las complicaciones con mayor frecuencia son: sangrado 61% presentada (13/21 artículos), estenosis traqueal 28,5% (5/21 artículos), decanulación 23,6% (5/21 artículos), infección de la estoma 19% (4/21 artículos) muerte 19% (4/21) y la dificultad en la inserción de la cánula 19% (4/21 artículos), en cuanto a factores de riesgo mecánicos para éstas sólo se identifica el uso de la técnica Bjork flap (OR=0,4). Entre los no mecánicos se encontraron, obesidad (OR=5,15), diámetro de cánula >6 (OR= 2,6) y ventilación mecánica preoperatoria (OR=3,14). Conclusión:Se logró identificar que las complicaciones relacionadas con la traqueostomía con mayor incidencia son sangrado, estenosis traqueal, decanulación accidental y la muerte. Sin embargo, aún se desconoce si se originan por una causa mecánica o no mecánica durante su manejo en UCI.

Resumen La broncoaspiracion del reflujo gastroesofagico (RGE) es uno de los principales factores de riesgo para la neumonia intrahospitalaria (NIH) y la neumonia asociada a la ventilacion mecanica (NAVM). En el ambito clinico de la vida real, la identificacion de las causas del RGE implica una complejidad diagnostica indiscutible, que varia a medida que el paciente esta bajo el cuidado critico. El RGE es modificable en estos pacientes, pero las intervenciones terapeuticas exigen la consideracion de un diagnostico integral de sus causas. Nuestra impresion es que existe un conformismo que interpreta que «ya hacemos todo lo necesario» para prevenir la broncoaspiracion y el RGE en estos pacientes. Si esto fuese cierto, unicamente podemos tener la expectativa de que el efecto Pigmalion convierta nuestras acciones actuales en el «ideal de prevencion» ante el riesgo de NIH. El nombre del efecto Pigmalion surge de un mito griego. Pigmalion era un escultor que se enamoro de Galatea, una de sus obras. Su amor era tan intenso que la creia una mujer real. La escultura cobro vida despues de un sueno del escultor. Este suceso fue denominado efecto Pigmalion, en el cual se superaron las expectativas y creer que la estatua estaba viva llego efectivamente a darle vida. Este mito no resolvera el grave problema que representa la NIH en la realidad de todos los centros hospitalarios del planeta. Por ello, la analogia del «pozo de petroleo» permite interpretar integralmente las causas de RGE y puede ser util para mejorar y agilizar el proceso diagnostico y terapeutico en pacientes criticamente enfermos, y resalta el caracter dinamico de dichas causas de RGE. El tratamiento habitual de un simple procinetico o la posicion semirecumbente se muestran insuficientes para evitar la neumonia nosocomial (NN), por lo cual se han propuesto e identificado otras multiples estrategias adicionales de prevencion. La investigacion traslacional (no el efecto Pigmalion) debe identificar estrategias innovadoras adicionales como dispositivos de aspiracion continua o intermitente, inteligencia artificial, realidad aumentada, o aplicacion de las tecnologias de la informacion y comunicacion (TICs) entre otros, para disenar nuevas formas de intervencion preventiva y terapeutica ante el riesgo de NIH en pacientes hospitalizados en Unidad de Cuidados Intensivos (UCI) por diversas causas y sus graves consecuencias.

La aparición del brote de coronavirus 2 (COVID-19) en China, a finales del 2019, se ha transformado en pandemia por un síndrome respiratorio agudo severo (denominado SARS-CoV-2). Este es un problema de salud pública (1). Hasta el momento se acepta que la transmisión es de persona a persona, por medio de gotitas producidas cuando hablamos o tosemos, o en contacto directo con las mucosas, como los ojos y la nariz, al llevarnos las manos contaminadas a dichos sitios (2). Se estima que la infección tiene un período de incubación promedio de 6,4 días, y un número de reproducción básico va desde 2,24 a 3,58 (3). Se han reportado 395 744 casos en el mundo, con mortalidad de 17 234 casos y 103 736 pacientes que se han recuperado (4). En Colombia, para el 24 de marzo, en total son 306 casos confirmados en el país según el último reporte, con 3 muertos para la fecha (5). Este artículo se diseñó para ofrecer recomendaciones a las unidades de sueño y laboratorios de función pulmonar en cuanto a la pandemia por coronavirus, con base en la evidencia que se ha publicado en los 3 últimos meses y en la opinión de expertos. Esto puede cambiar una vez se conozca más sobre la infección.

Desde diciembre del 2019 emergió la infección por coronavirus en el mundo, la cual se declaró pandemia por la Organización Mundial de la Salud (OMS) el 11 de marzo de 2020. Se estableció como epicentro la ciudad de Wuhan, capital de la provincia de Hubei, China (1). Rápidamente se identificó el agente causal de esta enfermedad, un betacoronavirus conocido como síndrome respiratorio agudo severo coronavirus 2 (SARS-CoV-2) (2). Al corte del 05 de junio de 2020, el Centro Europeo para la Prevención y Control de Enfermedades reportaba 6 475 644 casos, con 386 544 decesos en el mundo (3). Para esta misma fecha, en nuestro país se reportaban 35 120 casos y 1087 muertes (4).

Resumen Introduccion: estudios recientes han reportado la ocurrencia de fenomenos tromboticos o coagulopatia en pacientes con COVID-19 Hay posiciones divergentes en cuanto a la prevencion, el diagnostico y el tratamiento de estos fenomenos, y la practica clinica actual esta basada unicamente en deducciones por extension a partir de estudios retrospectivos, series de casos, estudios observacionales y guias internacionales desarrolladas previas a la pandemia Objetivo: establecer un grupo de recomendaciones sobre prevencion, diagnostico y manejo de las complicaciones tromboticas asociadas a COVID-19 Metodos: se desarrollo una guia rapida en la que se aplico el marco de la evidencia a la decision (EtD) de GRADE y un sistema de participacion iterativo, con analisis estadisticos y cualitativos de sus resultados Resultados: se generaron 31 recomendaciones clinicas enfocadas a: a) Pruebas de coagulacion en adultos sintomaticos con sospecha de infeccion o infeccion confirmada por SARS-CoV-2;b) Tromboprofilaxis en personas adultas con diagnostico de COVID-19 (escalas de riesgo, tromboprofilaxis de manejo ambulatorio, intrahospitalario y duracion de tromboprofilaxis despues del egreso de hospitalizacion), c) Diagnostico y tratamiento de las complicaciones tromboticas y d) Manejo de personas con indicacion previa a usar agentes anticoagulantes Conclusiones: las recomendaciones clinicas de este consenso orientan la toma de decisiones clinicas respecto a prevencion, diagnostico y tratamiento de fenomenos tromboticos en pacientes con COVID-19, y representan un acuerdo que ayudara a disminuir la dispersion en las practicas clinicas acorde con el desafio que nos impone la pandemia Introduction: recent studies have reported the occurrence of thrombotic phenomena or coagulopathy in patients with COVID-19 There are divergent positions regarding the prevention, diagnosis, and treatment of these phenomena, and current clinical practice is based solely on deductions by extension from retrospective studies, case series, observational studies, and international guidelines developed prior to the pandemic Objective: to generate a group of recommendations on the prevention, diagnosis and management of thrombotic complications associated with COVID-19 Methods: a rapid guidance was carried out applying the GRADE Evidence to Decision (EtD) frameworks and an iterative participation system, with statistical and qualitative analysis Results: 31 clinical recommendations were generated focused on: a) Coagulation tests in symptomatic adults with suspected infection or confirmed SARS CoV-2 infection;b) Thromboprophylaxis in adults diagnosed with COVID-19 (Risk scales, thromboprophylaxis for outpatient, in-hospital management, and duration of thromboprophylaxis after discharge from hospitalization), c) Diagnosis and treatment of thrombotic complications, and d) Management of people with previous indication of anticoagulant agents Conclusions: recommendations of this consensus guide clinical decision-making regarding the prevention, diagnosis, and treatment of thrombotic phenomena in patients with COVID-19, and represent an agreement that will help decrease the dispersion in clinical practices according to the challenge imposed by the pandemic

Introducción: se desconoce la incidencia y mortalidad atribuible al tromboembolismo pulmonar agudo en la región de Santander, Colombia. Objetivo: analizar los casos incidentes de tromboembolismo pulmonar agudo sintomático en el departamento de Santander que requirieron manejo hospitalario, su referenciación geográfica y su mortalidad atribuible. Métodos: estudio retrospectivo basado en los registros entre 2010 y 2014 tanto del Sistema Integral de la Información de la Protección Social de Colombia, como del Observatorio de Salud Pública de Santander y del Servicio de Estadísticas de nueve instituciones de salud de nivel de atención IIIV. Se analizaron variables demográficas como el lugar de procedencia y residencia, así como tipo de remisión y sus características, tipo de atención médica requerida, condición al alta y reingresos. Resultados: se identificaron 2879 atenciones por tromboembolismo pulmonar agudo en adultos con una mediana de edad 63 años, y razón mujer:hombre de 1.43. Los municipios con mayor incidencia fueron California (1093 por 100 000 hab.), Bucaramanga (278 por 100 000 hab.) y Málaga (257 por 100 000 hab.). La mortalidad total fue de 8.03 por 100 000 hab. Sólo 0.7% de las remisiones se hizo a través del Centro Regulador de Urgencias. Sólo 79 pacientes (17.52%) ingresaron a la unidad de cuidados intensivos. La incidencia de tromboembolismo pulmonar se correlacionó directamente con la altitud del lugar de procedencia (p= 0.01) e inversamente con el tiempo de acceso al municipio de referencia (p=0.021). Conclusiones: la incidencia de tromboembolismo pulmonar en Santander se estima en más del doble de lo reportado en otros países, y se correlaciona con la altitud del lugar de procedencia de los pacientes

Queremos compartir este reencuentro de todas/os los colegas afiliados, así como de los múltiples aliados de ASONEUMOCITO en el marco del XIX Congreso Colombiano Neumología y Cirugía de Tórax “MEDICINA RESPIRATORIA DE LA VIDA REAL” en Bucaramanga. El Palacio de Congresos de NEOMUNDO constituye un espacio ideal para que desde el 2 y hasta el 5 de marzo podamos compartir, planificar, discutir y avanzar en los objetivos transdisciplinares de nuestra asociación.

Chronic obstructive pulmonary disease (COPD) is a common, preventable, treatable lung disease characterized by persistent respiratory symptoms and airflow limitation and multiorgan impact. This affects the nutritional status of patients and requires multidimensional interventions including nutritional interventions according to individual metabolic needs. Our scoping review determined the effects of antioxidants in the treatment of COPD patients and their role in the decrease in the probability of exacerbations, hospital readmissions, and changes in lung function. The sources MEDLINE, LILACS, and Google Scholar were consulted and 19 studies were selected. The most indicated antioxidants are N-Acetylcysteine, vitamins E and D, and Zinc. Other antioxidants from plants or fruits extracts are also being investigated. The beneficial effect of antioxidants in stable or exacerbated patients is not clear, but theoretical and biological arguments of benefit justify lines of research that specify the impact on reducing oxidative stress and negative effects in COPD.

Objective: The soluble guanylate cyclase stimulator riociguat is approved for the treatment of adult patients with pulmonary arterial hypertension (PAH) and inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) following Phase 3 randomized trials. The EXPosurE Registry RiociguaT in patients with pulmonary hypertension (EXPERT) study was designed to monitor the long-term safety of riociguat in clinical practice. Methods: EXPERT was an international, multicenter, prospective, uncontrolled, non-interventional cohort study of patients treated with riociguat. Patients were followed for at least 1 year and up to 4 years from enrollment or until 30 days after stopping riociguat treatment. Primary safety outcomes were adverse events (AEs) and serious adverse events (SAEs) coded using Medical Dictionary for Regulatory Activities preferred terms and System Organ Classes version 21.0, collected during routine clinic visits and collated via case report forms. Results: In total, 956 patients with CTEPH were included in the analysis. The most common AEs in these patients were peripheral edema/edema (11.7%), dizziness (7.5%), right ventricular (RV)/cardiac failure (7.7%), and pneumonia (5.0%). The most common SAEs were RV/cardiac failure (7.4%), pneumonia (4.1%), dyspnea (3.6%), and syncope (2.5%). Exposure-adjusted rates of hemoptysis/pulmonary hemorrhage and hypotension were low and comparable to those in the long-term extension study of riociguat (Chronic Thromboembolic Pulmonary Hypertension Soluble Guanylate Cyclase–Stimulator Trial [CHEST-2]). Conclusion: Data from EXPERT show that in patients with CTEPH, the safety of riociguat in routine practice was consistent with the known safety profile of the drug, and no new safety concerns were identified. © 2020 The Authors Eli Lilly and Company; Pfizer; Bayer; GlaxoSmithKline; Merck; Actelion Pharmaceuticals; Meso Scale Diagnostics; United Therapeutics Corporation; Novartis Pharma; Merck Sharp and Dohme; GlaxoSmithKline Australia; Deutsche Forschungsgemeinschaft; Grupo Ferrer Internacional, S.A The EXPERT registry was funded by Bayer AG (Berlin, Germany) and Merck Sharp & Dohme Corp., a subsidiary of Merck & Co. Inc., Kenilworth, NJ, USA. The authors acknowledge the database administration by Torsten Tille, Dresden, and the project administration of Mrs Romy Hoppenz and Mrs Linda Kottke at GWT-TUD GmbH, Dresden. Medical writing services provided by Richard Murphy PhD of Adelphi Communications Ltd, Macclesfield, UK were funded by Bayer AG in accordance with Good Publication Practice (GPP3) guidelines. The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Prof Marius M. Hoeper reports personal fees from Bayer AG, during the conduct of the study; personal fees from Actelion, personal fees from Acceleron, personal fees from MSD, personal fees from Jansen, personal fees from Pfizer, outside the submitted work. Dr Hans Klose reports speaker and consultancy fees from Actelion, Bayer AG, GSK, Novartis, Pfizer, and United Therapeutics and research support from Actelion, Bayer AG, GSK, Pfizer, and MSD. Dr Michael Halank reports personal fees and non-financial support from Actelion, AstraZeneca, Bayer AG, Berlin-Chemie, GSK, OMT, MSD, and Novartis. Dr George Giannakoulas reports speaker and consultancy fees from Actelion, Bayer, ELPEN Pharmaceuticals, GSK, Pfizer, Lilly, and United Therapeutics, and research support from GSK, ELPEN Pharmaceuticals, and Galenica. Dr Henning Gall has received honoraria and/or other support from Actelion, AstraZeneca, Bayer, BMS, GSK, Janssen-Cilag, Lilly, MSD, Novartis, OMT, Pfizer, and United Therapeutics. Dr Pavel Jansa reports consultancy and speaker fees from MSD, AOP Orphan, and Actelion. Prof Ekkehard Grünig reports research grants and speaker honoraria/consultancy fees from Actelion and Bayer/MSD, research grants from GSK, United Therapeutics, Bellerophon, OMT GmbH, Pfizer, Reata, and Novartis, and speaker honoraria from Bial, Medscape, and OrPha Swiss GmbH. Prof David Pittrow reports personal fees from Actelion, Bayer AG, Aspen, Boehringer Ingelheim, Sanofi, Biogen, Shire, and MSD outside the submitted work. Silvia Ulrich reports research grants and personal fees from Actelion, Bayer, MSD, and Orpha Swiss. Tobias J. Lange has received personal fees from Actelion, MSD, Pfizer, and OMT orphan. Dr Iraklis Tsangaris reports speaker and consultancy fees from Actelion, Bayer AG, ELPEN, GSK, MSD, Pfizer, and United Therapeutics. Stephan Rosenkranz reports remunerations for lectures and/or consultancy from Abbott, Actelion, Arena, Bayer, Ferrer, GSK, MSD, Novartis, Pfizer, and United Therapeutics; and research support to his institution from Actelion, Bayer, Novartis, Pfizer, and United Therapeutics. Repke J. Snijder reports grants from Pfizer and Actelion Pharmaceuticals. Prof Iveta Šimková reports consultancy and speaker fees from MSD, AOP Orphan, and Actelion. Dr Marc Humbert reports grants and personal fees from Bayer and GSK, and personal fees from Actelion, Merck, and United Therapeutics. Marion Delcroix has received investigator, speaker, consultant, and steering committee member fees from Actelion, Bayer AG, Bellerophon, Eli Lilly, GlaxoSmithKline, MSD, Pfizer, and Reata, and research grants from Actelion. Joan A. Barberà reports receipt of honoraria for consultation or speaker fees from Actelion and Merck; and research support through his institution from Actelion, Merck, GlaxoSmithKline, and Ferrer. Joanna Pepke-Zaba reports research grants and speaker honoraria/consultancy fees from Actelion, Bayer/MSD, and GSK. Jean-Luc Vachiéry reports ongoing consultancies to Actelion, Sonnivie, Arena Pharma, Bial Portela, and Respira Therapeutics, past consultancies to AstraZeneca, BayerShering, CardioMEMS, GlaxoSmithKline, Pfizer, Merck, and United Therapeutics, and current membership of an advisory board or similar group for Actelion and GlaxoSmithKline. Jean-Luc Vachiéry's institution receives funding from Actelion Pharmaceuticals for performing clinical studies. Regina Steringer-Mascherbauer, Jens Klotsche, and Miguel-Angel Gomez Sanchez have no conflicts of interest relevant to the EXPERT study. Hossein-Ardeschir Ghofrani reports personal fees for advisory board work, and payment for lectures including service on speaker bureaus, from Actelion, Bayer, GSK, Novartis, and Pfizer; consultancy fees from Actelion, Bayer, Bellerophon Pulse Technologies, GSK, MSD, Novartis, and Pfizer; and grants from Deutsche Forschungsgemeinschaft (DFG). Pilar Escribano Subias reports personal fees from Actelion, Bayer AG, GlaxoSmithKline, and Merck Sharp & Dohme, and grants from Actelion, Bayer AG, GlaxoSmithKline, and Ferrer, outside the submitted work. Gérald Simonneau reports personal fees and non-financial support from Actelion, personal fees and non-financial support from Bayer, personal fees and non-financial support from MSD, outside the submitted work. Douglas S. Helmersen reports industry-sponsored research with Bayer AG, United Therapeutics, and Gilead Sciences, Inc., and advisory board/speaker fees from Bayer AG and Actelion. David Langleben reports honoraria, consultation fees, research support, and/or travel expenses from Actelion, Arena, Bayer AG, Northern Therapeutics, PhaseBio, Acceleron, Janssen, and United Therapeutics. Anco Boonstra reports consultancy fees from Pfizer BV and hospitality from Teva Nederland. Lisa M. Mielniczuk reports speaker fees and honoraria from Bayer AG, and speaker fees, consultancy fees, and travel fees from Actelion. Evgenia Williams and Christian Meier are employees of Bayer AG.

Estudios recientes han reportado la ocurrencia de fenómenos trombóticos o coagulopatía en pacientes con COVID-19. Hay posiciones divergentes en cuanto a la prevención, diagnóstico y tratamiento de estos fenómenos y la práctica clínica actual está basada únicamente en deducciones por extensión a partir de estudios retrospectivos, series de casos, estudios observacionales y guías internacionales desarrolladas previas a la pandemia. En este contexto, el objetivo del presente trabajo fue establecer un grupo de recomendaciones sobre prevención, diagnóstico y manejo de las complicaciones trombóticas asociadas a COVID-19. Métodos: Se desarrolló una guía rápida aplicando el marco de la evidencia a la decisión (EtD) de GRADE y un sistema de participación iterativo, con análisis estadísticos y cualitativos de sus resultados. Resultados: Se generaron 31 recomendaciones clínicas enfocadas a: a) Pruebas de coagulación en adultos sintomáticos con sospecha de infección o infección confirmada por SARS-CoV-2; b) Tromboprofilaxis en personas adultas con diagnóstico de COVID-19 (Escalas de riesgo, Tromboprofilaxis de manejo ambulatorio, intrahospitalario, y duración de tromboprofilaxis después del egreso de hospitalización), c) Diagnóstico y tratamiento de las complicaciones trombóticas y d) Manejo de personas con indicación previa de usar agentes anticoagulantes. Conclusiones: Las recomendaciones clínicas del presente consenso orientan la toma de decisiones clínicas respecto a prevención, diagnóstico y tratamiento de fenómenos trombóticos en pacientes con COVID-19, y representan un acuerdo que ayudará a disminuir la dispersión en las prácticas clínicas acorde con el desafío que nos impone la pandemia.

Los síntomas de pacientes con hipertensión pulmonar de grupo 1 ó 4 son malos predictores de su gravedad

Invención, producción y registro de un compuesto con sustratos específicos

La iniciativa de Red Colombiana de Hipertensión Pulmonar

Hallazgos preliminares del ensayo clínico multicéntrico de evaluación de la seguridad de la aspiración supraglótica continua

Las presiones subestiman la gravedad del deterioro del gasto cardíaco en pacientes con hipertensión pulmonar

Evidencia de respondedores y no-respondedores al tratamiento con medicamentos específicos de hipertensión arterial pulmonar en Colombia

Introduction: The use of extracorporeal membrane oxygenation (ECMO) has increased exponentially in recent years and has shown to be effective in treating adult respiratory distress syndrome (ARDS) secondary to H1N1-related pneumonia. However, evidence remains controversial. This study describes a case series of ECMO in ARDS secondary to viral pneumonia. Methods: A search was conducted in the ECMO database of Fundación Cardiovascular de Colombia for the 2013-2017 period. A case series report was written of patients diagnosed with ARDS secondary to confirmed or suspected viral pneumonia. Results: Nineteen patients with ECMO support and ARDS due to viral pneumonia were included in the study. The survival rate upon discharge was 11 patients (58%) and weaning from ECMO support was successful in 13 patients (68%). Hemorrhagic complications were the most frequent: gastrointestinal bleeding, 10 patients (53%); intracranial bleeding, 2 (10%); alveolar hemorrhage, 2 (10%);’ hemothorax requiring thoracostomy with chest tube drainage, 2 (10%); cannulation site bleeding, 9 patients (47%); and surgical site bleeding in 3 patients (25%) who required tracheostomy. Other complications were: pneumothorax, 1 patient (5%); sepsis, 6 patients (32%); and growth of microorganisms in bronchial lavage, 6 patients (32%). Conclusions: This study supports the use of veno-venous ECMO to achieve a higher survival rate than expected in patients with severe ARDS and refractory hypoxemia secondary to viral pneumonia. Early initiation of the therapy should improve overall results.

La enfermedad pulmonar obstructiva crónica es una importante causa de mortalidad y morbilidad a nivel mundial y tiene efectos psicosociales y fisiopatológicos que repercuten de manera significativa en la calidad de vida de quienes la padecen. Objetivo. Evaluar la calidad de vida de pacientes con enfermedad pulmonar obstructiva crónica a través del instrumento SF-36, versión en español para Colombia (SF-36 v2), en un servicio de consulta externa de Floridablanca, Colombia, durante el año 2015. Metodología. Estudio de corte transversal descriptivo realizado en 40 pacientes con diagnóstico de enfermedad pulmonar obstructiva crónica que asistieron al servicio de consulta externa por Neumología entre los meses de febrero y noviembre de 2015. El cuestionario SF-36 v2 fue diligenciado por todos los participantes; previamente, se firmó el consentimiento informado. La base de datos fue digitada, bajo licencia, en QualityMetric Health Outcomes™ Scoring Software 4.0. Resultados. Participaron 40 pacientes, con una edad media de 73 (DE ± 8.4) años. En las dimensiones de funcionamiento físico se encontraron valores inferiores a 50; por otra parte, las dimensiones Funcionamiento Social y Rol Emocional presentaron valores superiores y cercanos a los reportados por población sana. Conclusiones. Los pacientes con enfermedad pulmonar obstructiva crónica mostraron una disminución en la calidad de vida comparado con los valores de referencia en población en general en sus dos componentes: físico y mental. Se ratifica el impacto que tiene esta enfermedad en todas las subescalas que componen este constructo, especialmente en el componente físico. [Cáceres-Rivera DI, Roa-Díaz ZM, Domínguez CL, Carreño-Robayo JH, Orozco-Levi MA. Calidad de vida en adultos mayores con enfermedad pulmonar obstructiva crónica. Chronic obstructive pulmonary disease is one the most significant causes of mortality and morbidity worldwide. It has psychosocial and pathophysiological effects that impact in a significant way to those who suffer from it. Objective. To evaluate quality of life from patients suffering from chronic obstructive pulmonary disease through the SF-36 survey (Spanish version for Colombia (SF-36 v2)) made during an external medical appointment made in Floridablanca, Colombia in 2015. Methodology. Descriptive cross sectional study performed to 40 patients diagnosed with chronic obstructive pulmonary disease. These patients attended to external pulmonology medical appointments between February and November of 2015 and filled out the short form SF-36 v2 after signing informed consent. The database was created under license using QualityMetric Health Outcomes™ Scoring Software 4.0. Results. 40 patients, with an average age of 73 years (DE ± 8.4), participated in this study. When analyzing data, it was found that the physical functioning dimensions were values lower than 50. On the other hand, it was found that dimensions related to social functioning and emotional role had higher values and close to the ones reported by healthy population. Conclusions. Patients diagnosed with chronic obstructive pulmonary disease showed a decrease in quality of life, in both of its dimensions: physical and mental, compared to healthy population’s reference values. It is ratified that this disease impacts all sub-scales of this construct, specially the ones related to the physical component. [Cáceres-Rivera DI, Roa-Díaz ZM, Domínguez CL, Carreño-Robayo JH, Orozco-LeviMA. Quality of life in older adults with chronic obstructive pulmonary disease.

Resumen Introduccion La hipoxia tisular estimula la produccion de eritropoyetina (EPO) que tiene como principal funcion estimular la eritropoyesis. El SAHS es una entidad caracterizada por la presencia de episodios repetidos de hipoxemia durante el sueno. Objetivo Analizar si dicha hipoxemia es un estimulo suficiente para incrementar la excrecion urinaria de EPO. Si la respuesta fuera positiva, valorar si el tratamiento con presion continua positiva de la via aerea (CPAP) la inhibiria. Metodos Se han estudiado 25 sujetos con sospecha de SAHS, a los que se les realizo un estudio polisomnografico. En todos ellos se determinaron los niveles de EPO en la primera orina de la manana (uEPO), asi como los niveles de creatinina y hemoglobina en sangre. En los pacientes con SAHS grave se repitieron las mismas determinaciones tras el tratamiento con CPAP. Resultados Doce sujetos fueron diagnosticados de SAHS grave (media ± SD, IAH de 53,1 ± 22,7). La creatinina y la hemoglobina fueron normales en todos los sujetos. La uEPO fue cuatro veces superior en el grupo SAHS respecto a los controles (1,32 ± 0,83 vs. 0,32 ± 0,35 IU/l, p Conclusiones Los pacientes con SAHS grave muestran un incremento en su excrecion de uEPO, que se normaliza tras el tratamiento con CPAP.

Tissue hypoxia stimulates the production of erythropoietin (EPO), the main effect of which is, in turn, to stimulate erythropoiesis. Sleep apnea-hypopnea syndrome (SAHS) is an entity characterized by repeated episodes of hypoxemia during sleep.To analyze whether hypoxemia stimulated increased urinary excretion of EPO, and if so, to evaluate if treatment with continuous positive airway pressure (CPAP) can inhibit this phenomenon.We studied 25 subjects with suspected SAHS who underwent a polysomnography study (PSG). EPO levels in first morning urine (uEPO) and blood creatinine and hemoglobin were determined in all patients. Patients with severe SAHS repeated the same determinations after CPAP treatment.Twelve subjects were diagnosed with severe SAHS (mean ± SD, AHI 53.1 ± 22.7). Creatinine and hemoglobin levels were normal in all subjects. uEPO was 4 times higher in the SAHS group than in the control group (1.32 ± 0.83 vs. 0.32 ± 0.35 UI/l, p.002). CPAP treatment reduced uEPO to 0.61 ± 0.9 UI/l (p.02), levels close to those observed in healthy subjects. No dose-response relationship was observed between severity of PSG changes and uEPO values.Patients with severe SAHS show increased uEPO excretion, but this normalizes after treatment with CPAP.

Resumen El reflujo gastroesofagico (RGE) es uno de los principales factores de riesgo para la neumonia nosocomial, especialmente en pacientes bajo ventilacion mecanica. En el ambito clinico de la vida real, la identificacion de las causas del RGE implica una complejidad diagnostica indiscutible, que varia a medida que el paciente esta bajo el cuidado critico. El RGE es potencialmente modificable en estos pacientes, pero las intervenciones terapeuticas exigen la consideracion de un diagnostico integral de sus causas. La analogia del «pozo de petroleo» es una conceptualizacion integral de las causas de RGE que puede ser util para mejorar y agilizar el proceso diagnostico y terapeutico en pacientes criticamente enfermos. El tratamiento simple habitual de un procinetico y/o antiacido aparenta ser insuficiente. Los pacientes pueden requerir y beneficiarse de estrategias adicionales especificas, diferenciales e inclusive cambiantes en el tiempo segun cada caso y su evolucion. La analogia del pozo de petroleo facilita el ejercicio diagnostico multifactorial, resalta el caracter dinamico de dichas causas de RGE, y en consecuencia permite orientar la terapeutica de forma individualizada e igualmente dinamica en cada paciente.

Bronchial aspiration of oropharyngeal content is the main risk factor for ventilator-associated pneumonia (VAP). Intermittent aspiration is a common strategy to decrease this content. Nevertheless, it requires direct action and can induce local complications. Aim: To evaluate the eficacy and safety of continuous supraglottic aspiration by using the SUPRAtube (a device of own innovation) in patients receiving mechanical ventilation. Methods: Randomized clinical trial where SUPRAtube is compared with conventional aspiration techniques. To date, 50 adult patients (56±19 years) have been included. The device was inserted in the first 12 hours and fixed at the supraglottic nadir (pressure, -20 cmH2O). Efficacy was assessed by quantifying the volume of the aspirate. Safety was evaluated by through two consecutive videoendoscopies. Results: In the control group, the aspiration volume was 25±6 ml/day. In the SUPRAtube group it was 269±48 ml/day (p Conclusions: The continuous supraglottic aspiration using the new SUPRAtube device is a safe, simple and low cost technique able to avoid the accumulation of oropharyngeal secretions in mechanically ventilated patients. Supported by FCV and COLCIENCIAS, ref. 656677758334 (833-2017)

ResumenObjetivoDescribir la experiencia clínica de una serie de casos de pacientes adultos con hipertensión pulmonar tromboembólica crónica, llevados a tromboendarterectomía pulmonar.MétodosEstudio descriptivo, retrospectivo, de ocho pacientes adultos llevados a tromboendarterectomía pulmonar en la Fundación Cardiovascular de Colombia, entre febrero de 2010 y abril de 2013.Resultadosse evaluaron 5 mujeres y 3 hombres, con promedio de edad 45±18 años, datos basales promedio de SpO2 92±2%, PaO2/FiO2 244±82, PaCO2 28,8±3,4mm Hg, presión pulmonar media 53±11mm Hg y resistencia vascular pulmonar (RVP) 999±414dyn/s/cm−5. Al tercer día postoperatorio un paciente necesitó oxigenación con membrana extracorpórea (ECMO) venoarterial por 11 días. A los 4±1días de tromboendarterectomía pulmonar, la RVP descendió 71±21% respecto al valor basal (p=0,002, IC 95%) y la presión pulmonar media disminuyó 32±27mm Hg (p=0,001). La SpO2 basal aumentó 96±3%. La sobrevida fue del 100% a los 24 meses de seguimiento, sin reingresos ni recurrencia de tromboembolia pulmonar.ConclusionesLos resultados institucionales fueron adecuados a corto y mediano plazo. En casos de edema por reperfusión la alternativa de ECMO como soporte vital extracorpóreo es indispensable.AbstractMotivationTo describe clinical experience of a series of cases of adult patients with chronic thromboembolic pulmonary hypertension who underwent pulmonary thromboendarterectomy.MethodsDescriptive retrospective study of eight adults who underwent pulmonary thromboendarterectomy at the Fundación Cardiovascular de Colombia between February 2010 and April 2013.Results5 women and 3 men were assessed, with an average age of 45±18 years, with avergae baseline data of SpO2 92±2%, PaO2/FiO2 244±82, PaCO2 28.8±3.4mmHg, average pukmonary pressure of 53±11mmHg and pulmonary vascular resistance (PVR) of 999±414dyn/s/cm−5. On the third postoperative day one patient required veno-arterial extracorporeal membrane oxygenation (ECMO) during 11 days. At 4±1 days after pulmonary thromboendarterectomy, PVR decreased 71±21% with regards to baseline value (p=0.002, IC 95%) and pulmonary pressure was reduced to 32±27mmHg (p=0.001). Baseline SpO2 increased 96±3%. Survival rate was 100% after 24 months of follow-up, without readmissions or recurrence of pulmonary thromboembolism.ConclusionsInstitutional results were adequate in the short and medium term. Cases with reperfusion edema, the alternative of ECMO as an extracorporeal life support is imperative.

Background Hypercapnic encephalopathy is relatively frequent in severe exacerbations of COPD (ECOPDs), with its intensity usually being evaluated through clinical scales. Bispectral index (BIS) is a relatively new technique, based on the analysis of the electroencephalographic signal, which provides a good approximation to the level of consciousness, having already been validated in anesthesia. Objective The objective of the study was to evaluate the utility of BIS in the assessment of the intensity of hypercapnic encephalopathy in ECOPD patients. Patients and methods A total of ten ECOPD patients were included, and the level of brain activity was assessed using BIS and different scales: Glasgow Coma Scale, Ramsay Sedation Scale (RSS), and Richmond Agitation–Sedation Scale. The evaluation was performed both in the acute phase and 3 months after discharge. Results BIS was recorded for a total of about 600 minutes. During ECOPD, BIS values ranged from 58.8 (95% CI: 48.6–69) for RSS score of 4 to 92.2 (95% CI: 90.1–94.3) for RSS score of 2. A significant correlation was observed between values obtained with BIS and those from the three scales, although the best fit was for RSS, followed by Glasgow and Richmond (r=−0.757, r=0.701, and r=0.615, respectively; P, Video abstract

BACKGROUND: Lung resection surgery further decreases exercise capacity and negatively affects respiratory muscle function in patients with non-small cell lung cancer (NSCLC). The best design for exercise interventions in these patients has not been determined yet. AIM: To assess the impact of aerobic exercise and high-intensity respiratory muscle training on patient outcomes following lung cancer resection surgery. DESIGN: Prospective, single-blind, pilot randomized controlled trial. SETTING: Outpatient cardiopulmonary rehabilitation unit of two university hospitals. POPULATION: Thirty-seven patients with NSCLC after tumor resection. METHODS : Patients were randomly assigned to exercise training or usual post-operative care. The training program consisted of aerobic exercises and high-intensity respiratory muscle training (24 supervised sessions, 3 per week, 8 weeks). Primary outcome was exercise capacity assessed with peak oxygen uptake (VO2peak) during cardiopulmonary exercise test. Secondary outcomes included changes in respiratory muscle strength, levels of serum insulin growth factor I (IGF-I) and IGF binding protein 3 (IGFBP-3), and quality of life assessed with the European Organization for Research and Treatment of Cancer (EORTC ORTC QLQ-C30) questionnaire. RESULTS: The 8-week training program was associated with significant improvement in VO2peak (2.13 mL/Kg/min [95% CI 0.06 to 4.20]), maximal inspiratory and expiratory pressures (18.96 cmH(2)O [95% CI 2.7 to 24.1] and 18.58 cmH(2)O [95% CI 4.0 to 33.1], respectively) and IGFBP-3 (0.61 mu g/mL [% 95 CI 0.1 to 1.12]). No significant differences were observed in the EORTC QLQ-C30. CONCLUSIONS: An 8-week exercise program consisting of aerobic exercise and high-intensity respiratory muscle training improved exercise capacity, respiratory muscle strength, and serum IGFBP-3 levels in NSCLC patients after lung resection. There was no impact on the other outcomes assessed. CLINICAL REHABILITATION IMPACT: A combination of aerobic exercise and respiratory muscle training could be included in the rehabilitation program of deconditioned patients with NSCLC after lung resection surgery.

Resumen El tromboembolismo pulmonar (TEP) agudo es una complicacion potencialmente letal de la enfermedad tromboembolica venosa, con una mortalidad hasta del 10%. A largo plazo, el TEP cronico puede precipitar complicaciones y secuelas cardiopulmonares discapacitantes. Estas complicaciones pueden disminuirse mediante el diagnostico, clasificacion y tratamiento oportuno y adecuado. La indicacion del tratamiento del TEP agudo varia desde baja a altas complejidades. Se ha generalizado la asignacion del tratamiento segun un baremo multidimensional (clinico, ecocardiografico y biomarcadores) de clasificacion del riesgo de complicaciones mayores y mortalidad a 30 dias. El beneficio de la trombolisis farmacologica en los pacientes con TEP que cursa con shock cardiogenico tiene gran beneficio, interpretado como disminucion de la mortalidad. Sin embargo, tanto la trombolisis sistemica como la terapia endovascular en los pacientes sin shock sigue siendo un tema controvertido que justifica la investigacion actual. Presentamos el caso de un paciente adulto con TEP de riesgo intermedio de complicaciones mayores y muerte, definido por la presencia de disfuncion ventricular derecha y elevacion de marcadores de lesion miocardica. Se decidio llevar a cabo trombolisis intraarterial farmacologica y trombectomia mecanica mediante un sistema de aspiracion controlada (Penumbra System®, Penumbra Inc., EE. UU.). Este dispositivo fue desarrollado y esta validado para el tratamiento de neurotrombectomia, pero desconocemos reportes respecto de su uso como terapia endovascular mediante cateter en casos de TEP. En este primer caso describimos y discutimos resultados favorables evidenciados en la mejoria clinica y hemodinamica en reposo, sin evidencia de eventos adversos. Es posible que dispositivos como el Penumbra® puedan ofrecer alternativas adicionales de tratamiento endovascular mecanico mediante cateter en casos seleccionados de TEP agudo.

Background and objective Non-anaemic iron deficiency (NAID) might alter the oxygen pathway in health and disease. The current study aims at assessing the impact of NAID on aerobic capacity in patients with chronic obstructive pulmonary disease (COPD). Methods A prospective sample of 70 non-anaemic COPD patients candidate to participate in an 8-week pulmonary rehabilitation (PR) programme was studied. Incremental cycling exercise to peak oxygen uptake (V'O2peak) and constant work-rate exercise at 80% V'O2peak to exhaustion were assessed pre- and post-PR. Training-induced increase of endurance time (ET) ≥33%, which represented the minimal clinically important difference, classified patients as responders to exercise training. Results The prevalence of NAID was 48% (n = 34) showing no relationship with the Global Initiative for Chronic Obstructive Lung Disease stages (P = 0.209). Patients with NAID showed lower pre-training ET (P = 0.033) and V'O2peak (P = 0.007) than normal iron status (NIS) patients after adjustment for potential covariates. Significant training-induced physiological changes were seen in the NIS group (ΔV'O2peak 68(132) mL/min; P = 0.009), but not in the NAID group (ΔV'O2peak 26 (126) mL/min; P = 0.269). The NAID group showed lower percentage of responders to training (56%) than the NIS group (78%) (P = 0.041). Conclusions COPD patients with NAID showed lower pre-training aerobic capacity and reduced training-induced response than NIS patients after adjusting for potential confounding variables.

A proportion of patients with pulmonary arterial hypertension (PAH) and chronic thromboembolic pulmonary hypertension (CTEPH) do not achieve treatment goals or experience side effects on their current therapy. In such cases, switching patients to a new drug while discontinuing the first may be a viable and appropriate treatment option. CAPTURE was designed to investigate how physicians manage the switching of patients to riociguat in real-world clinical practice. Observations from the study were used to assess whether recommendations in the riociguat prescribing information are reflected in clinical practice. CAPTURE was an international, multicenter, uncontrolled, retrospective chart review that collected data from patients with PAH or inoperable or persistent/recurrent CTEPH who switched to riociguat from another pulmonary hypertension (PH)-targeted medical therapy. The primary objective of the study was to understand the procedure undertaken in real-world clinical practice for patients switching to riociguat. Of 127 patients screened, 125 were enrolled in CAPTURE. The majority of patients switched from a phosphodiesterase type 5 inhibitor (PDE5i) to riociguat and the most common reason for switching was lack of efficacy. Physicians were already using the recommended treatment-free period when switching patients to riociguat from sildenafil, but a slightly longer period than recommended for tadalafil. In line with the contraindication, the majority of patients did not receive riociguat and PDE5i therapy concomitantly. Physicians also followed the recommended dose-adjustment procedure for riociguat. Switching to riociguat from another PH-targeted therapy may be feasible in real-world clinical practice in the context of the current recommendations.

Resumen El angiomiolipoma (AML) es un tumor benigno de origen mesenquimal, compuesto por tejido adiposo maduro, vasos sanguineos aberrantes y musculo liso, con una prevalencia aproximada del 1-3% de todas las masas renales. Se han descrito presentaciones aisladas y relacionadas esporadicamente con Linfangioleiomiomatosis pulmonar y/o en el contexto del sindrome de esclerosis Tuberosa, siendo estos ultimos 2 contextos, mas dificiles en cuanto a diagnostico y manejo de intencion curativa. Presentamos el caso de una paciente diagnosticada con Angiomiolipoma Renal Gigante y Linfangioleiomiomatosis pulmonar esporadica no filiada, diagnosticada y manejada con nefrectomia izquierda previa embolizacion selectiva arterial, en la Fundacion Cardiovascular de Colombia. Conclusion El Angiomiolipoma Renal es una enfermedad de baja prevalencia, de diagnostico incidental en su mayoria, sin que requiera de intervencion mas que seguimiento por el urologo. Sin embargo, cuando nos enfrentamos a pacientes con grandes masas tumorales y/o multiples, sumado a manifestaciones clinicas, habra de pensar entre otros, a asociacion con Linfangioleiomiomatosis Pulmonar y/o sindrome de esclerosis tuberosa, entidades que constitu yen un reto desde el diagnostico hasta el tratamiento por un grupo multidisciplinario, en un intento por mejorar la calidad de vida de las afectadas. © 2013 Sociedad Colombiana de Urologia. Publicado por Elsevier Espana, S.L. Todos los derechos reservados.

Background and Aim Both interval (IT) and continuous (CT) exercise training results in an improvement of aerobic capacity in patients with chronic obstructive pulmonary disease (COPD); however, their effects on cardiac autonomic function remains unclear. The aim of our study was to evaluate the effect of a supervised CT vs IT on autonomic cardiac function in COPD patients. Methods COPD patients were divided into two different groups according to training modality (IT or CT). Autonomic cardiac dysfunction (ACD) was defined as a heart rate recovery lower than 12 bpm heart rate after the first minute of maximal exercise (HRR1) and an abnormal chronotropic response (CR) to exercise (

Introduccion La disfuncion muscular es una de las manifestaciones sistemicas mas estudiadas en la EPOC. Las alteraciones metabolicas musculares son dificiles de estudiar in vivo, debido a la falta de tecnicas no invasivas. El objetivo fue evaluar sincronicamente la actividad metabolica de diferentes grupos musculares en pacientes con EPOC. Metodos Se incluyeron 39 pacientes y 21 controles (funcion pulmonar normal), candidatos a realizacion de tomografia axial computarizada y por emision de positrones para estadificacion de lesion pulmonar localizada. Tras infusion de 18-fluor-deoxi-glucosa, se captaron imagenes de 2 musculos respiratorios (porciones costal y crural del diafragma, y recto abdominal) y 2 musculos perifericos (cuadriceps y biceps braquial), utilizando como indice de metabolismo glucidico el standard uptake value. Resultados Este indice fue superior en ambas porciones del diafragma comparado con el resto de los musculos en todos los sujetos. Ademas, el diafragma crural y el recto del abdomen mostraban mayor actividad en los pacientes con EPOC que en los controles (1,8 ± 0,7 vs. 1,4 ± 0,8; y 0,78 ± 0,2 vs. 0,58 ± 0,1; respectivamente; p < 0,05). El cuadriceps mostraba una tendencia similar. En los pacientes con EPOC los niveles de captacion de ambos musculos respiratorios y del cuadriceps se correlacionaron directamente con el atrapamiento aereo (r = 0,388; 0,427 y 0,361, respectivamente; p < 0,05). Conclusiones Existe mayor nivel de captacion-utilizacion de glucosa en el diafragma humano respecto de otros musculos en respiracion tranquila. Se confirma cuantitativamente que los pacientes con EPOC tienen incrementado el metabolismo glucidico de sus musculos respiratorios (con tendencia similar para el cuadriceps), en relacion directa con las cargas mecanicas que afrontan.

Summary Background The effects of obesity in combination with chronic obstructive pulmonary disease (COPD) on exercise capacity are receiving increased attention. But, a comprehensive analysis of factors associated with aerobic capacity in obese COPD patients has not been performed. Methods Six-min walking test (6MWT) was performed in 251 COPD patients, and 159 of those also carried out an incremental cardiopulmonary exercise test (CPET) to evaluate exercise capacity. In all patients, anthropometrics, dyspnea and anxiety–depression scores, lung function, daily physical activity, co-morbidities and circulating inflammatory biomarkers were also assessed. Six-min walking distance (6MWD) and peak oxygen uptake (VO 2 peak) during CPET were two primary outcome variables. Results 57% of the patients showed body mass index (BMI) 2 (COPD N ) and the remaining 43% were obese with a BMI ≥ 30 kg/m 2 (COPD O ). In patients with COPD N , 6MWD showed independent negative associations with age, dyspnea score, sedentarism, depression scores and a positive relationship with arterial oxygenation; whereas in COPD O , 6MWD showed an inverse relationship with BMI. In COPD N , VO 2 peak showed a negative association with age and positive relationships with both FEV 1 and DL CO. However, in COPD O the dyspnea score was the strongest determinant of VO 2 peak. Conclusions Obese and non-obese COPD patients show different determinants of aerobic capacity, including pulmonary and non-pulmonary factors that are also dependent on the type of exercise protocol. These results could be considered in the evaluation of obese patients with COPD.

Cigarette smoking is the main cause of chronic obstructive pulmonary disease (COPD). Diaphragm injury is observed in patients with COPD. However, the potential role of smoking in triggering or perpetuating muscle injury is unknown. The present study was aimed at evaluating the potential role of commercial tobacco smoke as a direct cause of skeletal muscle injury in experimental conditions. Seventy Wistar rats (170 - 250 g) were assigned to smoking (n = 49) or non-smoking (n = 21) groups. The smoking groups were submitted to a single or multiple (i.e., five or thirty) daily sessions of cigarette smoking in an inhalatory chamber (time length: 2 h each session). The level of exposure was constant and assessed by CO concentrations (50 ppm) and serum cotinine analysis. Animals submitted to a single smoke exposure and the corresponding controls were euthanized in groups at 0 h, 2 h, 4 h, 24 h or 48 h after completing the exposure. Animals submitted to multiple exposures were euthanized at 0 h after smoking. Samples from vastus lateralis muscle were obtained and processed for assessing cell injury and selected protein expression. Monoclonal anti-albumin antibodies were used to identify muscle fibers with sarcolemmal (membrane) injury. Subcellular muscle injury was assessed using transmission electron microscopy (EM). MyoD, myogenin and α-tubulin were immunodetected using western blot techniques. Exposure to cigarette smoke associated with significant membrane damage (mean relative difference (MRD) with controls: +181%, p = 0.004) and sarcomere disruptions (MRD: +226%, p = 0.001). Expression of MyoD and myogenin (normalized to α-tubulin) were significantly increased at 4 h and remained increased at 48 h post-exposure. We conclude that not only a single but also consecutive exposure to tobacco smoke have acute deleterious effects on peripheral muscle structure. A rapid induction of subrogate markers of skeletal muscle stress and repair processes associates to sarcolemmal and sarcomere damage.

Muscle dysfunction is frequently observed in chronic obstructive pulmonary disease (COPD) patients, contributing to their exercise limitation and a worsening prognosis. The main factor leading to limb muscle dysfunction is deconditioning, whereas respiratory muscle dysfunction is mostly the result of pulmonary hyperinflation. However, both limb and respiratory muscles are also influenced by other negative factors, including smoking, systemic inflammation, nutritional abnormalities, exacerbations and some drugs. Limb muscle weakness is generally diagnosed through voluntary isometric maneuvers such as handgrip or quadriceps muscle contraction (dynamometry); while respiratory muscle loss of strength is usually recognized through a decrease in maximal static pressures measured at the mouth. Both types of measurements have validated reference values. Respiratory muscle strength can also be evaluated determining esophageal, gastric and transdiaphragmatic maximal pressures although there is a lack of widely accepted reference equations. Non-volitional maneuvers, obtained through electrical or magnetic stimulation, can be employed in patients unable to cooperate. Muscle endurance can also be assessed, generally using repeated submaximal maneuvers until exhaustion, but no validated reference values are available yet. The treatment of muscle dysfunction is multidimensional and includes improvement in lifestyle habits (smoking abstinence, healthy diet and a good level of physical activity, preferably outside), nutritional measures (diet supplements and occasionally, anabolic drugs), and different modalities of general and muscle training.

Background: Bladder and lung cancer are among the ten most common cancers in both genders. The NKG2D receptor and one of its ligands, MICA, are associated with smoking and susceptibility to both chronic obstructive pulmonary disease and lung cancer. Objective: We hypothesized that NKG2D-MICA system was associated with other smoking-related epithelial cancers such as bladder cancer. Design, Setting, and Participants: 70 cases of primary non-muscle invasive bladder cancer were screened for the MICA expression and CD8+, CD4+ and NK cell infiltration. Most patients (n = 55, 78.6%) were current or former smokers. Measurements: Tissue microarray (TMA) technology was chosen to evaluate MICA and tumor infiltrating lymphocytes in samples with confirmed bladder cancer. Kaplan-Meier curves and univariate Cox analysis was used to assess relapse, all-cancer mortality and specific bladder cancer mortality. Results and Limitations: MICA was expressed in most cancer specimens examined (i.e., 70%). Relapse of bladder cancer was not associated with the status of MICA expression (log rank p = 0.1123). Nevertheless, a significant association existed between high MICA expression and bladder cancer mortality (HR = 0.25; CI95% = 0.06 - 0.97). Tumor infiltrating CD4+ and CD8+ lymphocytes were found in the majority (64%) of samples. Cells expressing the NKG2D receptor were found in only 3% of the samples. There was no linear function between NKG2D+ cells and number or ratio of CD4+ and CD8+ TIL. Conclusions: MICA is expressed in a significant proportion of bladder carcinomas. MICA expression associates with significant survival advantages in the face of both all-cancer and bladder cancer. The NKG2D-MICA system could represent a common mechanism involved in the immunopathology and natural history of bladder neoplasms.

Extracorporeal membrane oxygenation (ECMO) is widely used in acute respiratory distress syndrome (ARDS) and myocarditis. Severe vector-mediated diseases may be complicated by ARDS or myocarditis, which are both associated with a high mortality rate. We present six cases of severe dengue, malaria, and acute Chagas disease that were treated with ECMO from September 2007 to September 2015. Patients included two pediatric and four adults (aged 12-48). Survival to decannulation was 83% and to discharge was 66%. Overall, the mean duration on ECMO was 25.4 days. We conclude that ECMO treatment can be beneficial in patients with severe dengue, malaria, and acute Chagas disease, if complicated by pulmonary or cardiac complications.